Bulletin of the World Health Organization

Maasai couples seek safer solutions to infertility

Infertility is a public health problem that affects all societies, not least traditional ones such as the Maasai of East Africa. In this Bulletin interview, Weiyuan Cui talks to Dr Yadira Roggeveen, a medical officer at Endulen Hospital in the Ngorongoro Conservation Area in the United Republic of Tanzania.

Yadira Roggeveen
Courtesy of Yadira Roggeveen
Yadira Roggeveen

Dr Yadira Roggeveen obtained her Master of Science and Doctor of Medicine degrees at the Free University of Amsterdam (VU) in the Netherlands. She worked for the Public Health Department in Amsterdam. Since 2008, she has been working at Endulen Hospital, a remote 72-bed facility in the Ngorongoro Conservation Area in the United Republic of Tanzania. As a medical doctor, her focus is on maternal health and paediatrics. She started and chaired the Safe Motherhood Project of Endulen Hospital, to evaluate reproductive health-care services and strengthen communciation between the hospital and the community.

Q: How prevalent is infertility in the Maasai community?

A: When I started working at Endulen Hospital (in 2008) not one patient reported infertility problems to me. Since then, the number of cases has been increasing slowly, as a result of increased trust and willingness to report the problem. By May 2010, 25% of the female patients at my outpatient consultations were reporting an inability to conceive. All can be epidemiologically defined as infertility cases, as these women had had unprotected sexual intercourse for more than two years. However, no study on the prevalence of infertility has been conducted in this area.

Q: Why is infertility so high in this community?

A: Many of the women that I have counselled on infertility had a history of a sexually transmitted infection (STI). Factors that are known to increase the risk of STIs include having had the first sexual contact at an early age and multiple sexual partners, combined with a polygamous marriage structure. Condom use – to prevent STIs – is low, as many Maasai people believe it is a waste of semen. But STIs are not the only cause of infertility. Tuberculosis and unsafe delivery practices can also cause infertility.

Q: Is infertility a new problem for the Maasai people?

A: No. Traditionally, Maasai society has developed creative solutions to infertility. If a woman did not conceive, her husband often permitted her to have sexual relationships with other men. Sometimes she went on a special journey for this purpose. If the woman conceived, the children were regarded as her husband’s children. But people are realizing more and more that this traditional solution can lead to health problems, such as HIV. Couples are therefore looking for safer solutions to overcome infertility.

Q: What is the attitude to infertile women?

A: Women have limited say over money and goods. It is very important for a woman to have a husband or male relative to take care of her. Having children affirms her blessed relation to Engai [God], strengthens the relationship with the children’s father and can secure inheritance of cattle via her sons. Traditionally, men hold decision-making power in Maasai society. They own the cattle, which are the main source of both food and income. If women do not have a husband or are not well taken care of, which is often true of infertile women, they may feel forced to ask for support from another man in return for transactional sex, and this creates new risks.

Q: Do safer infertility treatment options exist for this community?

A: Risky sexual behaviour has been used to solve fertility problems for a long time in this community. Changing this will be difficult and can only be achieved in time, with education about prevention, diagnostic options and treatment so that people have an alternative to traditional solutions to infertility. Otherwise, infertile couples put themselves at risk of STIs, including HIV infection. At Endulen Hospital ultrasound services, semen evaluation and counselling are available. More advanced infertility treatment options are available in Arusha, about a one-day journey away.

Q: What sort of programmes are in place?

A: Endulen Hospital runs health education programmes, which include reproductive health, in secondary schools. Adolescents that do not go to school are hard to reach as they are mostly away with the cattle during the day. The hospital deploys extensive outreach clinics in child and maternal health by car and plane. On top of this, hospital staff sets up special campsites in remote corners of our catchment area. The staff then travels around in the area to offer voluntary counselling, testing and care for HIV, as well as education on STI prevention. Currently, these programmes do not educate people on the link with prevention of infertility.

Q: You talk about Maasai women and infertility, what about the men?

A: Talking about the male factor in infertility is difficult. It takes a lot of counselling to persuade the men to have their semen tested or to accept treatment for STIs. Some men may not realize that they have fertility problems because, without their knowledge, their wives may have conceived with another sexual partner. During my consultations on infertility, the men have generally been supportive and caring when their wives had problems conceiving. But I have also heard stories of infertile women whose husbands have left them or who receive less care than other women who have children with the same man.

Q: What is needed to improve infertility services in rural and remote communities?

A: The Maasai, both men and women, seem relieved whenever infertility, safe motherhood, HIV/AIDS and contraception are addressed together in a single consultation. The people are more likely to discuss birth spacing and request contraception when reproductive health issues are presented more holistically. Doctors should inform and educate men and women on these topics, including infertility in each consultation related to reproductive health. More research into the causes of infertility could help to tailor solutions to remote communities. But hospitals need support from institutions and governments by making trained staff, educational materials, diagnostics (such as hysterosalpingogram or similar technologies) and treatment available in remote areas. When these are not available, there should be referral options.

Q: How do the Maasai people view family planning?

A: Planning a family and addressing maternal health in the community I serve means safely having the number of children a couple would like. I hear that in the past the Maasai regarded family planning as offensive, especially when it meant reducing family size and practising birth control. Overpopulation is not only discussed among scientists, but also in the Maasai community. They wonder if their children, their people, are not wanted. Having children is regarded as one of the most important things in life, as they are seen as a blessing from Engai. I think we have an obligation, as health workers, donors and policy-makers, to listen to the voices in the communities we work with and adapt strategies in sexual and reproductive health to the local setting. We mustn’t let infertile couples in remote communities feel they will not be helped or that they are part of a hidden plan to curb population growth.

Q: Infertility treatment is expensive, even for people in developed countries. What infertility treatment options are you able to offer?

A: Although not all infertility is preventable, information is the key to the infertility that is. Also, access to diagnostic tools and appropriate advice to couples can lead to overcoming infertility and to safe pregnancy. There have been some successful pregnancies after referral of both men and women to Arusha for more complex diagnostics and treatment. In counselling, one has to be honest and explain that a referral does not guarantee success. Lastly, counselling helps people cope with infertility, but every community has its own view on the subject. Even my responses are only reflective of the local Maasai, and an example of just one indigenous group that faces the challenge to incorporate prevention strategies and solutions to infertility within their rich tradition.